GCS IN OLD PEOPLE

unknownWe traditionally use GCS to triage patients who sustained traumatic brain injury. Some previous studies have reported how the accuracy of using GCS decreases with increasing age. Specifically, the elderly present with a higher GCS than younger patients when suffering the same injury. A large study presented in EMJ confirms those findings.

The paper
screen-shot-2016-10-09-at-13-16-23This is another massive database study coming out of the TARN project. It includes 25.082 patients, comparing ‘old patients’ (n=10.936, mean age 81 years) and ‘young patients’ (n=14.146, mean age 37 years) in regards to the presenting GCS after isolated traumatic brain injury. GCS was plotted against AIS severity score as well as mechanism of injury and type of injury. The AIS is a coding system describing the location and anatomical severity of injuries.

Results
The study confirmed the findings of previous studies in that presenting GCS was higher in elderly patients than in the young patient group when suffering the same severity of TBI. Interestingly, the difference increase with increased severity score. In the AIS grade 5 (critical injury) group the mean GCS was 9 in the young group versus 14 in the elderly.

Two previous smaller studies have reported the same phenomenon. That time the difference was suggested to be due to different mechanisms or types of injury. Therefore, the EMJ study further sub-grouped the patients. Again the presenting GCS was higher in the elderly patients regardless of the mechanism or type of injury.

Take-home message
To achieve the same reduction in GCS as younger patients, more severe injury is required in the elderly. This will inevitably result in under-triaging brain injury in older patients and will obviously result in delayed surgery and poor outcomes. At least as long as we use GCS or levels of consciousness as a triaging tool.

We probably knew this, but for me this paper is another nail in the coffin for the GCS as a clinical decision and triage tool.

For more on this, watch Mark Wilsons excellent take-down of the GCS (at least in the way we use it) at SMACC. It’s here.

The paper lives here (open access):

Older patients with traumatic brain injury present with a higher GCS score than younger patients for a given severity of injury. Kehoe A, Smith JE, Bouamra O, Edwards A, Yates D, Lecky F. Emerg Med J. 2016 Jun;33(6):381-5. 

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2 Responses to GCS IN OLD PEOPLE

  1. Samarrae says:

    What are the other nails in the coffin for the GCS ??

  2. GandhiTwo says:

    I have not yet heard the excellent take-down of the ubiquitous GCS, but I’m shure there are some good points to be heard. What I am not so impressed by is the conclusions that GCS is not a useful tool in the elderly. Grouping patients by energy of trauma (e.g. fall from similar height) and similar anatomical graded TBI cannot sufficiently predict actual severity. It would be very surprising if an aged brain floating in a retarively roomy cranium was equally damaged by the same energy as a young brain with little room to spare. The anatomical grading system AIS is hardly a well validated prognostic tool either. I for one am not surprised that older people can take a bigger punch to the head than the young. More room to move means less abrupt decelleration. Increasing the time for the energy to be absorbed by the brain should result in less diffuse axonal injury and a higher overall GCS following the traumatic insult. My conclusion is that old brains can take more of a beating than young brains. Short term mortality is likely lower in advanced age, but over weeks-months it may well be higher for the elderly. This does not mean the TBIs were comparable. Mortality in the elderly is more complex due to preexcisting comorbidity and lower degree of rehabilitabilty. In conclusion: Im sticking with the GCS. As prognostic tools go, GCS post-trauma pre-intubation combined with radiological imaging is the best we have. In most cases we still wont know much until we wake our TBI patients up.

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